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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Child maltreatment

Actions to take:

Interview the child separately from the parents

Ask a parent, away from the child

Parameters to monitor:

Signs of fear or apprehension from the child when either parent is present

Negative comments about child from either parent.

Rationale:

Potential Condition: Child Maltreatment

The client’s history of multiple injuries (bloody nose, sutures from hitting cabinet, and spiral fracture) in the context of the parent’s alcohol intoxication, slurring, and aggressive behavior raises concern for possible child maltreatment. The child’s statement about being "clumsy" and the observed scars also support the need for further investigation into possible abuse.

Actions to Take

Interview the child separately from the parents: To ensure the child can speak freely and report any concerns without the influence or presence of the parents, especially when maltreatment is suspected.

Ask a parent, away from the child: The parent should be interviewed privately to assess their behavior and any possible stressors or issues that could indicate abuse or neglect, especially considering their appearance and actions when visiting the child.

Parameters to Monitor

Signs of fear or apprehension from the child when either parent is present: This could indicate emotional distress or fear related to the parent’s behavior. It is important to observe how the child reacts to the presence of each parent during assessments.

Negative comments about the child from either parent: Verbal abuse or negative comments can be a red flag for emotional abuse or neglect. Careful attention should be paid to any signs of verbal maltreatment.

Potential Diagnoses: Incorrect Choices

Muscular Dystrophy: While this could explain a pattern of injury due to muscle weakness, it does not align with the history of multiple injuries caused by trauma or the current family dynamics.

Constipation: No evidence or symptoms supporting constipation were observed in the current assessment.

Strabismus: No direct evidence to suggest strabismus in the child’s history or exam.

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Correct Answer is C

Explanation

A. While obtaining culture specimens is important, the priority in this case is managing the child’s airway, as drooling and difficulty swallowing suggest potential airway obstruction.

B. Administering an antipyretic is not the priority; airway management is more urgent in this situation.

C. The priority is to prepare for intubation, as the child’s symptoms suggest possible epiglottitis, which can cause rapid airway obstruction. Securing the airway is critical.

D. Inserting an IV catheter is important for hydration and medication administration, but airway management is the immediate priority.

A. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing B. A client who has a burn injury to an estimated 5% his leg and is crying C. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation D. A who is client 1 day postoperative and has a temperature of 37.5° C (99.5° F)

Correct Answer is A

Explanation

Rationale:

A. Orthostatic hypotension (a significant drop in blood pressure when standing) could indicate a problem such as dehydration, hemorrhage, or shock and should be reported immediately.

B. Crying due to pain is common with burn injuries but does not indicate a life-threatening problem.

C. A pain increase after ambulation is expected in some cases but is not an emergency.

D. A mild temperature (99.5°F) postoperatively is not a cause for immediate concern.

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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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